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ENVIR0NM1RllqTAL HEALTH DErARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 m <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 n 1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK MAR 16 2016 <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: �CPI_.H f1FQ�RT1111�A{T <br /> ❑TANK RETROFIT 0 PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> D Facility Name �° Phone# <br /> Address <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> c Contractor Name Phone# ,GJ- --Fj-71 G3 <br /> N Contractor Addresses( �,�K `C;� � % �f CA Lic# �1�—�5- Class <br /> R Insurer <br /> A Work Comp# <br /> TICC Technician's Name C-7t S­;" Expiration Date -,4.4—/ -7 <br /> R ICC Installer's Name , � �: �� Expiration C� C• <br /> /1 ? ��� %5 p' ation Date --7 <br /> Tank system work area Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T -- <br /> A <br /> N <br /> K <br /> P n Approved 1 Approved with conditions ❑ Disapproved <br /> L <br /> A ,� (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title(rl / + Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing <br /> Jby signature and date below. <br /> NAME 13 �Ca /� /�L'Zf�/LGt`l� TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE 1 3L�� DATE <br /> EH230038(revised 10/30/12) <br /> 2 <br />